"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Tuesday, January 31, 2012

California and Florida Physical Therapy Bills Move Forward

Physical therapists across the United States have gotten off to a fast start in 2012, as evidenced by two bills moving forward in California and in Florida.

California Senate bill SB 924 allows consumers to go directly to a physical therapist for treatment without first going through their doctor.

Senator Curren Price's bill was approved unanimously Monday, January 30th, 2012.

The Senate bill is a compromise bill that requires a therapist to refer a patient to doctors if the therapist learns that the patient needs medical attention.

It also requires the therapist to get a doctor's approval if the therapy goes beyond 12 visits or 30 business days.

Previous versions of the bill were opposed by the politically powerful California Medical Association (CMA). The CMA has not taken a position on the new compromise bill. The bill now goes to the California State Assembly.

Also, congratulations to the Florida Physical Therapy Association (FPTA) which scored an impresive victory Tuesday, January 17, 2012 as HB 799, the physical therapy temporary license bill by Rep. Tom Goodson passed out of its first committee of reference.

HB 799 by Rep. Goodson amends chapter 486, Florida Statutes, to allow Physical Therapy graduates of accredited programs, who are waiting to take the exam after graduation, to work under a temporary license permit.

The graduate would work under the direct supervision of a physical therapist while working (in the same room) and could only function in this temporary capacity until the results of the first exam are known. A licensed physical therapist may only supervise one temporary licensee permit at a time.

If the graduate with a temporary permit passes, they can continue working under the temporary permit until the permanent license is issued. If the graduate fails the exam, the temporary license is revoked and they may not work until passing the exam.

The legislation will also grant a similar license to physical therapist assistant graduates. Again, they would work under the direct supervision of a physical therapist. Similarly, if the exam is passed, they may continue working but cannot continue if the exam is failed.

Saturday, January 28, 2012

New Decision Support Tool Prevents Diagnostic Errors

Physical therapists practicing in a direct access setting of performing diagnostic work may find these new tools helpful to maintain a low rate of missed diagnoses.

Isabel Healthcare of Ann Arbor, Michigan and the British Medical Journal (BMJ) of London, England came together to create a new diagnostic decision support tool to help doctors diagnose rare diseases that may be overlooked in the busy clinical environment.

The doctor enters key patient findings into the computer or handheld device and the computer returns a list of potential diagnoses with high-risk "Don't Miss" diagnoses flagged.

A 2009 report titled Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors revealed the top misdiagnoses in medicine. Of 669 cases, the following misdiagnoses were reported:
DiseaseNumber of casesIncidence
Pulmonary embolism26 cases4.5% of total
Drug reactions or overdose 26 cases 4.5%
Lung cancer 23 cases 3.9%
Colorectal cancer 19 cases 3.3%
Acute coronary syndrome 18 cases 3.1%
Breast cancer 18 cases 3.1%
Stroke 15 cases 2.6%

Isabel is a 10-year old clinical decision support tool that has been validated in the peer reviewed literature and is endorsed by the American Medical Association (AMA)

BMJ Best Practice is a point-of-care decision support tool that provides the latest evidence-based medical information from the BMJ Evidence Centre.

Prevention of diagnostic errors can lead to improved accuracy and time of diagnosis and better treatments for patients.

Timing of Diagnostic Errors
Testing phase: failure to order, report, and follow-up laboratory results 44%
Clinician assessment errors: failure to consider and overweighing competing diagnosis32%
History taking10%
Physical examination10%
Referral or consultation errors and delays3%

This new tool may be of interest to physical therapists who practice in a direct access or primary care setting.

Increasingly, physical therapists are being asked to perform diagnostic decision making in direct access or primary care settings.

The use of new tools and new technologies should help physical therapists maintain a low rate of misdiagnoses.

Wednesday, January 25, 2012

Psst! Want a HOT tip? Form your own Physical Therapist Association...

All kidding aside, newly formed physical therapist associations seem to be a growth industry lately.

Full disclosure, I am on the Board of Directors of the Florida Physical Therapists in Private Practice (FLPTPP).

However, I do not belong to any of the following:
  • Physical Therapy Business Alliance (PTBA)
  • Physical Therapy Alliance of Upstate New York (PTAUNY)
  • New Jersey Society of Independent Physical Therapists (NJSIPT)
Perhaps there are unmet needs among physical therapist businesses that these groups are forming to address. According to the PTBA website:

"While our profession has successful organizations of "individuals" (American Physical Therapy Association, Sections of the Association, Components), a void exists in which the professional interests of physical therapy can be championed as businesses."
These three groups are organized to support the business activities of private practice physical therapy clinics. According to the PTAUNY website:
"The purpose of this organization was and is to keep the private practice owners and therapists informed of local and national trends, promote our practice, provide continuing education opportunities and communicate with local third party payers on issues that affect the services we provide."
The common thread of all three groups seems to be declining reimbursement and an inability of private practice physical therapists to act collectively. especially when negotiating third party insurance contracts. According to the FLPTPP website:
"... we will assist our members to control their financial well-being through improved reimbursement, sharing of expertise & best practices, and volume purchasing power."
While some traditional physical therapist organizations may feel stifled by these newly-formed groups, I think there is still plenty of oxygen left in the room.

Some of these groups, like the NJSIPT, have their own Political Action Committee (PAC) for soliting contributions. Will that decrease contributions to traditional physical therapist associations?

No, I don't think it will. There are more PACs in existence in 2012 than EVER in history and this Presidential election will require EACH political party to raise $1 BILLION dollars to field a candidate.

Does the presence of seperate groups confuse legislators who may be used to just one PT group per state?

No, just look at the physicians' societies - in Florida we have the following:
  • 1 Florida Medical Association
  • 17 sub-specialty physician asosciations (eg: orthopedics, family practice, etc.) AND
  • 67 county medical societies, one for each of the Florida counties.
By the way, EACH of these physician groups donates to their PAC to support their own (sometimes conflicting) interests. Do you think Florida legislators are confused by all the physician medical societies?

Not as long as the money keeps flowing! :)

Monday, January 23, 2012

Florida Temporary Licensure - From a Ripple to a Wave

I got my first real taste of the less glorious side of politics when I spent 2009 and 2010 passing out flyers, attending fundraisers, and throwing candy for Chad Hays, my step father, now State Representative for the 104th district in Illinois.

Fast forward to January 16th, 2012—myself, some close peers, and colleagues in Physical Therapy are attending the Advocacy Forum put on by the Florida Physical Therapy Association (FPTA) in Tallahassee, Florida.

The 2012 FPTA Advocacy Forum was a success.

The forum allowed students and clinicians to learn more about the political process, how to advocate for our profession culminating with attendees having the opportunity to observe our own bill navigate a key House committee.

After our bill was introduced to the sub-committee by Representative Goodson, I joined other physical therapists in giving testimonials.

The bill passed unanimously in the Health and Human Services Quality sub-committee. The advancement of our bill that day has created a ripple effect. The result forwards the ultimate goal of allowing new graduates to practice while waiting to sit for board exams, but also splashes into important directions relating to the association’s future.

Equally important is the impact on the dozen physical therapy students in attendance at the capital in concert with the excitement from those students still in class on the home front who were kept notified through social media. Representing the future of the profession, we have truly seen democracy at work . . . .SO EXCITING.

Temporary licensure was re-exposed by a student this September to the FPTA in Orlando at a district caucus during the association’s annual conference. At the general assembly gathering the next day, University of St. Augustine students were recognized for raising $1000 for PT-PAC. Soon thereafter we each witnessed the organization quickly vote in support to pursue the legislature. Furthermore, not only did students witness their dollars at work, the receptiveness by the practicing clinicians to the idea served as justification and encouragement to students who do not think their voice could be heard. It further served as validation to those individuals who moan and grumble on the fees for FPTA/APTA membership they pay.

Here we are today, spearheaded by young professionals who juggle the rigors of doctoral education and sacrifice valuable study time (more importantly free time) to advocate for their trade. I felt as proud as when I had received my acceptance letter to PT school as the number of students at the advocacy forum exceeded the amount of practicing clinicians.

Thank you for making a difference.

The undulation of the Temporary Licensure stone thrown into the pool of politics is further seen in the development of the organization’s relationship with Tallahassee. We have made headway not only with our sponsors in the House (Rep. Tom Goodson) and in the Senate (Senator Bill Montford), but also with Doctor of Osteopathic Medicine Ronald Renuart, the vice chair of the Health and Human Services Quality Subcommittee. Eric Chaconas, PT, DPT, FAAOMPT and I were introduced to “Doc” Renuart in Jacksonville last fall.

The receptiveness from Representative Renuart that day left me feeling that the FPTA would have a tough road ahead of them.  However; Rep. Renuart was in full support of our bill on Tuesday arguing that Florida produces great physical therapists and we need to keep them here!

Anything is possible. We need to keep the swell that we have created this January 2012 session from turning into a tsunami headed in our own direction.

The day was a success. I am not looking at the glass optimistically as if it were half full. I am certainly not looking at the glass pessimistically as if it were half empty. I am however looking at the glass opportunistically; to drink it. Simply put, as a member of the FPTA, we need to evaluate and reflect our triumphs and mishaps. The organization, location, and presentations given during the advocacy training were terrific. Awesome hotel, food, excellent support information, and presentations that were interesting, helpful, and informative.

However, our sponsor in the House thought we were massage therapists. At one point, I had to explain to him that physical therapists were to bones and muscles as dentists were to gums and teeth so he would stop raving about the massages he has had before. He was good for a non-controversial issue, but what about direct access or dry needling? He clearly did not know the field.

There were many questions that could have been anticipated (dates, how it was before, why tests dates) but had to be answered by several different individuals because one could not fully articulate the nuances of our field. In fairness, legislators are bombarded with issues from hundreds of fields; the education of our elected officials is our job. The advancement of our bill that day has created a ripple effect that shouldn’t be left unrecognized.

I read a blog by Mike Reinold, a physical therapist that I hope to meet someday, and Head Athletic Trainer/Assistant Director of Medical Services for the Boston Red Sox. The article highlighted the common adage used in physical therapy called the “kinetic chain.” Dr. Reinold’s focal point was that far too often the body is more analogous to a ripple in the water with some parts not following the notion “a chain is only as strong as its weakest link”. He noted that the body follows a “kinetic ripple.”

My extreme love for Anatomy and Biomechanics was put on the back burner, for I found the ripple synonymous with our progress in the state capital on January 17th. I was intrigued in that the correlation heads in all directions. Perhaps we can all look further into Temporary licensure in that not only does the legislation create jobs for new graduates, but also lays the foundation for the future of young practitioners, their involvement, and the success for the organization at the Capital. FPTA staff, students and clinicians…stay diligent, because you never know what’s over the next wave.

Leighton Peavler, SPT, FPTA, GAC
Student Representative, University of St. Augustine for Health Sciences
For comments and questions, please do not hesitate to contact Leighton at LeightonPeavler@gmail.com

Saturday, January 21, 2012

Why Politics Is Important to Physical Therapists

Congratulations to Eric Chaconas, DPT of the Florida Government Affairs Committee and and Scott Harp, PhD Vice President of the Florida Physical Therapy Association for hitting their attendance goals for the 2012 Florida State Advocacy Training program in Tallahassee on January 16 and 17, 2012.

Thirty five physical therapists and physical therapist assistants attended and the 2012 Advocacy Day was a HUGE success!
"FPTA members were treated to visits during the Advocacy Workshop by both Senator Montford and Rep. Goodson who offered praise and strong support for physical therapist and students taking time to travel to Tallahassee to advocate for their profession.
“The perfect lobbyist for the physical therapy profession is physical therapists and your students in training,” said Senator Montford.
Why is politics important for the physical therapist?

I highly recommend Charles Krauthhamer's excellent article in the Washington Post on December 30th which asks Are We Alone in the Universe?

Don't worry, its not science fiction - rather, Krauthhamer posits that politics is the driver of history and the organizer of our affairs:
"This is the work of politics — understood as the ordering of society and the regulation of power to permit human flourishing while simultaneously restraining the most Hobbesian human instincts.  
There could be no greater irony: For all the sublimity of art, physics, music, mathematics and other manifestations of human genius, everything depends on the mundane, frustrating, often debased vocation known as politics (and its most exacting subspecialty — statecraft).  
Because if we don’t get politics right, everything else risks extinction.  
We grow justly weary of our politics. But we must remember this: Politics — in all its grubby, grasping, corrupt, contemptible manifestations — is sovereign in human affairs. Everything ultimately rests upon it.  
Fairly or not, politics is the driver of history."

Friday, January 20, 2012

Value-based Healthcare Does NOT Reduce Medicare Spending

The blog of the Congressional Budget Office (CBO) announced yesterday that 30 years of Medicare demonstration projects have failed to show Medicare how to reduce healthcare spending in a Fee-for-Service environment.

The Issue Brief from the CBO describes two thirty-year initiatives:

  1. "Disease management and care coordination demonstrations have sought to improve the quality of care of beneficiaries with chronic illnesses and those whose health care is expected to be particularly costly.

  2. Value-based payment demonstrations have given health care providers financial incentives to improve the quality and efficiency of care rather than payments based strictly on the volume and intensity of services delivered."
Physical Therapy in a Value-Based Healthcare World by Dr. Julie Fritz in the January Journal of Orthopedic and Sports Physical Therapy (JOSPT) discusses three challenges physical therapists face in delivering care in a value-based environment:

  1. Multi-disciplinary care processes where the outcomes are NOT determined by one specialty or professional. These processes may have long time horizons - such as recovery from a stroke.
  2. Lack of functional outcomes measurement relevant to the patient.
  3. Provider payments that encourage greater volume of services than necessary.
Bob Laszewski's perspective at the Health Care Policy and Marketplace Review is that Almost Nothing Works to slow the growth rate of Medicare spending.

Laszewski goes on to question assumptions about Medicare Accountable Care Organizations (ACO) and whether they can slow cost growth by putting providers at risk for failure to achieve improvements in population health, like average blood sugar (HbA1c) levels for a whole group of people.

However, there are examples of value-based purchasing and disease management programs that DO work: they seem to return 3-for-1 in financial terms and they generate great patient satisfaction scores.

Except, they aren't run by the government.

Large private employers, like Toyota Motors and Perdue Farms, are BUILDING their own healthcare systems.

These private firms are improving health outcomes.

They save money.

And, patients like their healthcare.

Physical therapists in private practice can prepare for value-based purchasing by reaching out to private employers - find out what they want and figure out how we can bring it to them at a cost they can afford.

Value-based purchasing and healthcare reform is too big a problem, and too big of an opportunity, to leave to the government.

They'll just mess it up.

Wednesday, January 18, 2012

Prevent Internet Censorship

The Stop Online Piracy Act (SOPA) centralizes the power to regulate the Internet in contents creators: essentially large corporations, like Sony Music and the Disney Corporation, among others. Join the virtual strike against Internet censorship – along with others like Wikipedia and Google – to raise awareness of US Congress legislation that could fundamentally alter the Internet we know and love.

This harmful legislation, called the Stop Online Piracy Act (SOPA) in the House and the PROTECT IP Act (PIPA) in the Senate, will be voted on as early as January 24th in the Senate. If you live in the US, there's still time to help stop these bills from becoming law.

Consider reaching out to your Senator or House member by phone. You can say the following:
"I am writing to you as a voter in your district. I urge you to vote "no" on cloture for S. 968, the PROTECT IP Act, on Jan. 24th. The PROTECT IP Act is dangerous, ineffective, and short-sighted. It does not deserve floor consideration.   
I urge my representative to vote "no" on SOPA, the corresponding House bill.  
Over coming days you'll be hearing from the many businesses, advocacy organizations, and ordinary Americans who oppose this legislation because of the myriad ways in which it will stifle free speech and innovation.  
We hope you'll take our concerns to heart and oppose this legislation by voting "no" on cloture."
What makes this legislation so bad? Here's how it would change the Web:
  • Communication platforms – from YouTube to Facebook to Amazon – could be shut down if a single rights holder alleges a violation.
  • It would make the Web less stable and less secure.
  • Social networking sites, like Twitter or Facebook, could be forced to track and control user behavior, stunting innovation and undermining free expression.
  • Your Internet provider could be required to inspect all of your traffic and browsing.
If you trust the government you don't need to do anything.

Otherwise, pick up the phone, cally your representative and ask them to vote "No" in the Senate on S.968 and on SOPA in the House.

Friday, January 13, 2012

New Book on Clinical Decision Support in Physical Therapy

The new book is finally done!

Bulletproof Expert Systems began in 2006 when myself and six other physical therapists and physical therapist assistants attempted to standardize our clinical documentation.

From those early beginnings, in a series of workbooks, clinical manuals and in-services and, finally, seminars - this book was born.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting shows how physical therapist mangers and clinic owners can use existing clinical tools (such as paper-based or electronic outcome measures) to do the following:
  1. standardize documentation
  2. improve decision making
  3. improve productivity
  4. create a brief, transparent clinical record that will defy a Medicare audit
  5. improve your clinical outcomes
The publisher's web page went live January 7th, 2012 where I am providing the book at a substantial (~40%) discount from the on-line retailers.

You can buy the discounted book at the publisher's web site.

Finally, I need help selecting the final banner design - if you could just vote for one of the three finalists below I will be all set.

Thank you for your patience and the encouragement I have recieved from all my readers!

This have been an amazing educational and professional journey and its one I could not have made without you!

Thank you!

Thursday, January 12, 2012

Do We Need Physical Therapists or Algorithms?

"Do you use Treatment Based Classification algorithms?" I asked my friend in Florida. 
"No", she replied.  
"Why not?" I asked. "
If I use an algorithm, where's the need for the physical therapist?" was her final answer.
My friend is a busy, private practice owner who is well-respected for her focus on the patient and her clinical skills.

Physicians, too, resist using computer algorithms to inform treatment decisions for similar reasons.

I've discussed this trend before, most notably in response to the surprising results at the Oxford Debate at the 2011 American Physical Therapy Association Annual Meeting in Washington DC where student physical therapists lead the room AGAINST clinical decsion rules.

Now, Vinod Khosla, tech investor and CEO of Sun Microsystems, questions whether Do We Need Doctors or Algorithms?

Essentially, Vinod's argument boils down to the fact that computers and computer algorithms are faster, cheaper and less likely to make a mistake.

Humans, on the other hand, are non-perfect and non-perfectable.

The odds are against physicians and physical therapists if we try to pit human productivity and human efficiency against machine productivity and machine efficiency. But, healthcare is NOT just productivity and efficiency. Healthcare is also caring.

According to Jeremy Rifkin in The End of Work:
"...the role of humans as the most important factor in production is bound to diminish in the same way that the role of horses in agricultural production was first diminished and then eliminated by the introduction of tractors".
I think physical therapists are in good position to incorporate decision algorithms into our practice WITHOUT losing jobs.

Humans still prefer to be cared for by other humans. Chris Anderson author of The Long Tail, describes algorithms, like Wikipedia or Google as:
"…operating on the alien logic of probabilistic statistics - a matter of likelihood rather than certainty....our brains aren’t wired to think in terms of statistics and probability. 
We want to know whether an encyclopedia entry (or a doctor) is right or wrong. We want to know that there’s a wise hand (ideally human) guiding Google’s results. We want to trust what we read.”
Physical therapists are among the most trusted of healthcare professionals. Besides, we work with our hands and we still touch the patient.

I don't think Vinod has an algorithm for that.

Wednesday, January 11, 2012

Mary Hayashi Gets Probation

As described on this blog, California Assemblymember Mary Hayashi was arrested for shoplifting on October 28th, 2011.

Hayashi received the following punishment:
  1. three years probation,
  2. she paid a $180 fine
  3. she has been ordered to stay 150 feet away from the Nieman Marcus store where she committed her felony grand theft.
Stephanie Ong Stillman, a spokeswoman for the San Francisco District Attorney's office, says that a medical condition claimed to affect Mary Hayashi's "judgement and concentration" did not affect the judge's ruling.
"Her (medical) condition never factored into our decision," she said.
Incredibly, Mary Hayashi's medical condition, a brain tumor, has resolved spontaneously and she is able to continue with her current legislative duties serving Hayward County.
"Now that Ms. Hayashi's medical condition resulting in her arrest has been taken care of, she decided that she would resolve the case as well," Rappaport said.
"It is being treated," he added. "It's no longer affecting her concentration or her judgment."
Physical therapists living and working in California may have difficulty believing that Assemblywoman Hayashi's judgement has not and will not continue to be affected since she attempted to pass legislation permitting physician ownership of physical therapists in 2011, with over $2 million dollars in campaign donations paid by the California Medical Association and its doctors.

Read the full story at STOPPOPTS.org

Tuesday, January 10, 2012

Florida Legislative Session Opens Today!

Florida physical therapists get ready to lobby!

The start of the 2012 Florida Legislative session is today, January 10th, 2012.

Physical therapists can learn to set up their Bill Tracker with the Florida Senate video and with the Florida House of Representatives video, below.

2:03 min.

If you've never so much as picked up a phone to call your legislator then this may be YOUR year.

The Florida Physical Therapy Association (FPTA) is committed to helping you organize at the grassroots level.

Go to their web site at FPTA.org and find out how you can get invloved.

Watch this video and sign up for Bill Tracker to get started.

Monday, January 9, 2012

Provocative Position by American College of Physicians Calls for "Parsimonious Care"

The American College of Physicians (ACP) issued first-of-its-kind guidelines specifically calling for "parsimonious care" Monday.

Listen to the National Public Radio (NPR) interview here.

The 6th Edition of the ACP Ethics Manual is not a Clinical Practice Guideline so no direct implications are implied for physicians' practice patterns.

In other words, physical therapists shouldn't expect the kind of dramatic shifts in patient referral patterns suggested by the Virginia Mason/Aetna or the Intel/Cigna critical pathways much discussed lately.

But, this is the first time that ANY medical society has advised their physician members to consider cost when making patient care decisions. From the Manual:

"In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches."
Some people are concerned about the word "parsimonious". They are concerned that this word has a negative conotation that, in the polarized debate over heathcare reform, could be associated with rationing care. As used in the Manual...
"Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available."
For physical therapists, information on the most efficient care will most likely come from comparative effectiveness studies.

In high-volume conditions such as lower back pain and arthritis guidelines will likely support a shift away from routine imaging, invasive testing and surgical treatment.

Friday, January 6, 2012

Disruptive Innovation in Physical Therapy

Selena Horner noted in her Twitter stream: "Data doesn't create change... stories that evoke emotion create change..."

Collaborating Reduces Costs of Health Care is such a story.

The story appeared in the Money section of USA Today on January 6th, 2012. The article tells a story about an employee of Intel Corp. and its insurance company, Cigna of Oregon.

Peter Cady, who works 12-hour shifts on his feet at Intel's plant here, occasionally suffers severe lower back spasms. But he nearly gave up seeking medical help because in the weeks it took to get a doctor's appointment and a referral to physical therapy, the pain usually subsided.

These days, he's much happier with his care.

Rather than waiting to see a doctor, Cady and other patients with routine back pain now see a physical therapist within 48 hours of calling, compared with about 19 days previously, Intel says.

They complete their treatment in 21 days, compared with 52 days in the past.

The cost per patient has dropped 10% to 30% due to fewer unnecessary doctor visits and diagnostic imaging tests. And patients are more satisfied and return to work faster.
"It's a real bureaucracy buster that gets you right straight to someone who can take care of the problem," says Cady, 47.
"Before, the doctor wasn't helping me or explaining anything. But the physical therapist educated me, gave me stretches and exercises to do, and cleared it up."
Why is USA Today breaking this story?

Physical therapists are REPLACING physicians as the primary providers of musculoskeletal care. Physical therapists are stealing physicians' caseloads.

Why aren't the physical therapists involved in this pilot project speaking up, blogging, tweeting and shouting from the rooftops?

The Intel/Cigna model is much like the Starbucks/Virginia Mason model of distruptive innovation - market-based solutions, rather than government mandates, that lower the cost of healthcare to employers and patients.

Physical therapist employees will see more work by disrupting traditional physician caseloads - but what about physical therapist employers?

What about the private practice physical therapists who employ physical therapists?

Will we be disrupted, too?

I'd like someone to tell THAT story.

Wednesday, January 4, 2012

Chiropractic Services in Florida Have High Error Rate

First Coast Service Options (FCSO) is estimating an improper payment error rate of 39 percent for chiropractic services in Florida for the November 2011 CERT report. These payment errors often involve the billing of chiropractic manipulation services that represent maintenance care.

Providers’ adherence to Medicare coverage guidelines for chiropractic services continues to be a significant issue in Florida and the nation.

Based on previous national findings, CMS requested that the Comprehensive Error Rate Testing (CERT) program perform a special study of chiropractic services in 2012. The CERT special study on Florida chiropractic services yielded an overall error rate of 86.91 percent.

The vast majority of the services reviewed were denied for insufficient documentation and for not being medically reasonable and necessary.

Aside from documentation issues, the primary reason for payment errors in chiropractic services is maintenance therapy being billed as active treatment. This continues to be an issue, even after CMS implemented an acute treatment modifier to allow providers to differentiate maintenance from active treatment on submitted claims.

To help reduce and prevent improper payment errors, FCSO is reviewing data to identify beneficiaries receiving chiropractic services at routine intervals for extended periods of time and will develop beneficiary specific edits.

Here are some additional resources:
Here is the checklist for chiropractic providers to follow to assure that their services, when properly documented, demonstrate medical necessity for care. This checklist is being provided as a tool to assist providers when responding to medical record documentation requests.

It is the responsibility of the provider of services to ensure the correct submission of all required documentation. Review the following prior to submitting documentation for medical review.
  • Please be sure documentation submitted is legible. 
  • Please submit records for all dates of service on the claim. 
  • Ensure the medical records submitted supports that the service is “Active treatment,” rather than maintenance.
  • Ensure the medical records provide justification supporting medical necessity for the service by submission of the following:
    • Progress notes 
    • Initial and subsequent visits 
    • Treatment record including plan of care 
    • Abbreviation list 
    • Signatures/credentials of professionals providing services 
  • Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the additional documentation request (ADR) letter.
This information is relevant to physical therapists because we often treat the sames patients (chronic lower back pain, for example) and we often suffer from the same errors in documentation that chiropractors suffer from.

The Medicare 2010 CERT Report can be found here.

Monday, January 2, 2012

Cognitive Behavior Therapy Over the Telephone Effective for Chronic Widespread Pain

Physical therapists who treat chronic pain patients may be interested in this new randomized controlled trial of 442 patients comparing cognitive behavioral therapy (CBT) and an exercise program over 6 months.

As background information, the researchers described why alternatives to pharmacologic management, such as CBT and exercise, are necessary:
"In the United States, mean per-patient costs, including the following:

  • pain and non-pain-related medication,
  • physician consultations, 
  • tests and procedures, 
  • and emergency department visits 

...in the six months following a new diagnosis of fibromyalgia were $3,481"
The researchers compared telephone-delivered cognitive behavioral therapy (TCBT), graded exercise, combined intervention, or treatment as usual (control group). The results are shown in this chart:
Rate of Positive Outcomes
Time FrameControl groupTCBT groupExercise groupCombined Exercise and TCBT
6 months (end of intervention)8.1%29.9%34.8%37.2%
9 month follow-up8.3%32.6%24.2%37.1%

Cognitive Behavior Therapy...
"...represent a management strategy that puts patients firmly in charge.  
The skills learned in CBT, for example, are available after hours and over long weekends and do not require monthly refills
Moreover, because CBT can be administered by telephone, this intervention is convenient and can be made available to a wide range of patients."
The implications for physical therapists practicing in "traditional" settings with standard techniques and interventions are these:
  1. Notice the deterioration of exercise-only 9-month outcomes - we know this to be true since most patients don't stick with their exercises once they start feeling better.
  2. The TCBT group treatment were delivered over the telephone - this new delivery method is a threat to our traditional, clinic or hospital-based delivery and payment structure.

  3. Presumably, similar technologies such as the following:
  • Voice Over-Internet-Protocol (VOiP, or Skype),
  • Simple Message Syndication (SMS, or text),
  • social networks or
  • old-fashioned e-mail
...could work just as effectively.

I'd be curious to hear about therapist treating chronic pain patients using Cognitive Behavioral Therapy. I would like to learn some of these techniques.

I believe behavior-based interventions using non-traditional delivery methods represent the future for our profession.


Sunday, January 1, 2012

MicroSoft Xbox 360 Hackers Assess Gait, Measure Knee Angle

Are you still using your plastic goniometer?

Maybe its time to throw it away and get the new Microsoft's Xbox 360 to measure your patients' knee angles

The Kinect works, according this National Public Radio podcast by of the Siemens Competition in Math, Science and Technology teams winners, Ziyuan Liu:
"...the Kinect actually has two cameras and a laser emitter, so the laser emitter scatters little laser dots around the environment and that one of the cameras senses the distortion in these laser dots to measure depth and the other camera takes in the picture of the environment and correlates that with the depth.
And with that, we're practically able to reconstruct the environment in 3D, but our project focuses on extracting certain points like joints, knee angles."
This "disruptive technology" has the potential to displace physical therapists' jobs.

Physical therapists have traditionally measured gait deviations and knee joint angles using visual assessment for gait and plastic goniometers for knees.

I don't think most physical therapists have much to worry about since we still provide better value for common, high-volume musculoskeletal care than most primary care practitioners and care comparable to orthopedists at a fraction of the cost.

We looked in-depth at physical therapists replacing physicians in hospital settings here.

Thank you to Edwin Linares of the LinkedIn HITECH Professionals networking group for his re-post of "5 Trends That Will Shape the Future in 2012".

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

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American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.